Coordination of Care Initiative Mora Area Community

Transcription

1 Coordination of Care Initiative Mora Area Community Community Meeting October 9, 2018 FirstLight Health System Download meeting agenda and slide handout: Agenda Presentation handout 2 1

2 Welcome Introductions 3 Meeting Agenda and Objectives Share stories of success and challenges related to care transitions Discuss care coordination efforts across Minnesota; Review community scorecard reports Verbalize the three priority findings for Congestive Heart Failure population in Kanabec County at the completion of the presentation Identify action items for the Congestive Heart Failure population in Kanabec County at all levels of prevention at the completion of the presentation 4 2

3 Coordination of Care Initiative Update 5 Coordination of Care Initiative Goals Improve quality of care for Medicare beneficiaries who transition among care settings Reduce 30-day hospital readmission rates and admission by 20% by 2019 Increase the number of days at home Establish sustainable, transferrable transition practices across the spectrum of care 6 3

4 Coordination of Care Communities 7 COPD Webinar Series Webinar 1: COPD 101 recording available Webinar 2: COPD Patient Care Options to Reduce Readmissions recording available Webinar 3: Interdisciplinary Inpatient COPD Program recording available Webinar 4: Care in Advanced COPD: Prognosis, Planning, and Palliation recording available Webinar 5: Pulmonary Rehabilitation recording available 8 4

5 Perham Area Subgroup COPD Tool 9 Learning & Organizing in Action (LOA) Workshops Thursday, November 1, 2018, 8:30 a.m. 4:30 p.m. Register Tuesday, November 13, 2018, 8:30 a.m. 4:30 p.m. Register Stratis Health Classroom, 2901 Metro Drive, Bloomington, MN Cost: Free Community organizing initiative developed by ReThink Health Learn how to exercise leadership to engage others in population health and quality improvement. Understand how to organize and mobilize partners and stakeholders. Workshops are the same each day, so choose the date that works best for you. Space is limited, so please register soon. More > 10 5

6 Home Health Gap Collaborative Gap between the number of patients referred to home health services by the discharging hospital and the number who actually receive services. (Only about 55% receive HH services in MN.) Those patients that are referred but do not receive home health services have a significantly higher readmission rate (27% vs. 17.8%) Virtual MN-statewide collaborative with HHAs and hospital discharge planners, SNFs, and others to narrow the gap Partner organizations: Minnesota Home Care Assn (MHCA), Minnesota Hospital Association (MHA), Stratis Health Two workgroups: Patient/family/staff education, Discharge Planning Process If interested in joining or learning more: 11 Other Opportunities Best Practice Sharing Calls Communication/Pt. Family Engagement (recording available) Advance Care Planning (recording available) Mental Health/behavioral health/social determinants of health (no recording available) Discharge planning, readiness, pathway, d/c resources (recording available) November 20, 12-1:00 p.m. - Medication Safety CMS Collaborative Event: The Role of Data in the Opioid Crisis - October 10, 10 a.m. 12:00 p.m. Antibiograms: Supporting Antibiotic Stewardship Across the Community - October 25, 1-2:00 p.m. Depression and Chronic Illness: Focus on CKD & ESRD November 14, 2:30 3:30 p.m. Register at

7 Community Comparison Home Health Uptake 13 Community Scorecard 14 7

8 The Community 15 Admissions (community) 16 8

9 Admissions (comparative) 17 Admissions (vs. goal) 18 9

10 Number of Fewer Admissions Needed to Meet Goal This community had 1,068 admissions in the most recent 12 months (Q Q1 2018). Need to be at 1,067 admissions for final measurement (Q Q ), which is 3 fewer readmissions than is needed to meet the goal! Keep up the great work!! 19 Readmissions (community) 20 10

11 Readmissions (comparative) 21 Readmissions (vs. goal) 22 11

12 Number of Readmissions Needed to Meet Goal This community had 183 readmissions in the most recent 12 months (Q Q1 2018). Need to be at 193 readmissions for final measurement (Q Q ), which is 10 fewer readmissions than is needed to meet the goal! Keep up the great work! 23 ED Visits (community) 24 12

13 ED Visits (comparative) 25 Observation Stays (community) 26 13

14 Observation Stays (comparison) 27 MTM Visits 28 14

15 Next community meeting Date and time of the next community meeting is to be determined. Stay tuned for an announcement from Stratis Health. 29 Live Well at Home State Grant Opportunity Rose Dunn, Mora HRA Housing Coordinator 30 15

16 Best Practice Presentation 31 Triple Aim Clinical Project / Presentation: Congestive Heart Failure Jennifer Friday Submitted to Dr. Roger Green DNP, FNP, PMHNP, FAANP in partial fulfillment of NR609 Population Health Interprofessional Collaboration Regis University August 19,

17 Introduction Population: Congestive Heart Failure(CHF) patients Kanabec county FirstLight Health System (FLHS) patients Potential for 320 patients with CHF and 38 of those with < HS education Synthesis Gaps in care CHF readmissions Purpose Clinical problem Interdisciplinary Approach Who FLHS Kanabec county Public Health (KCPH) Stratis Health community collaborative partners Teams Care Transitions Patient Experience Stratis Health Community Collaborative Patient and Family Advisory Council Disciplines Nurses Social workers Pharmacists Therapists Dietitians Wellness coordinator Quality professionals Preceptor: Diane Bankers Patients 17

18 Triple Aim Population Health Synthesis Purpose Best possible care and outcomes Goals Bringing all components together Components Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of health care (The IHI Triple Aim, 2018) Triple Aim Components Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of health care 18

19 Goals of Project Reduce readmissions to the hospital Improve patient quality of life Data Collection Methods Primary Interviews Service learning experience Participation on teams at FLHS Secondary Resources and literature search Documents to review from team members/organizations Webinars 19

20 Primary Data Within the Hospital Stay Within 48 Hours of Hospital Discharge Within 7 days of Hospital Discharge RN Care Coordinator 1-1 education Follow-up call (if not pharmacist) Bedside Nurse Cares and education Pharmacist Med reconciliation Follow-up call if has medication therapy management (MTM) visit Social Worker Age 70 years and older Follow-up call if on weekend MTM visit (if available) Dietitian With referral With a referral from provider Cardiac Rehab Review record for referral With referral and ejection opportunities fraction <35% Home Care Visit Ongoing, if homebound If patient agrees Rehab Facility Stay Need 3 day hospital stay for Medicare Primary Care Provider Visit In clinic Follow-Up Phone Call 2 attempts If not reached, continue to call (A. Strom, personal communication, June 5, 2018) (R. Dahlquist, personal communication, June 15,2018) (K. Dvorak, personal communication, June 14, 2018) (D. Gilbertson, personal communication, July 4, 2018) (A. Korte, personal communication, June 13, 2018) (A. Berg, personal communication, June 25, 2018) Secondary Data Nation Minnesota Kanabec County Minnesota Counties, other Heart Failure Death Rate per 100,000 (any mention), , All Races/Ethnicities, Both Genders, Heart Failure Hospitalization Rate per 1,000 Medicare Beneficiaries, 65+, All Races/Ethnicities, Both Genders, Cost of Care per Capita for Medicare Beneficiaries $5,582 $2,119-10,823 Diagnosed with Heart Disease, 2015: Inpatient Costs Diuretic Nonadherence Percentage, Medicare Part D Beneficiaries, Aged 65+, 2015 Obesity, Age-Adjusted Percentage, (Interactive Atlas of Heart Disease and Stroke Tables, 2015) (Interactive Atlas of Heart Disease and Stroke, 2014) 20

21 Priority Findings Effectiveness of education Medication adherence issues Dietary adherence and understanding issues Synthesis Clinical Problem: CHF patients say they understand the skills needed to take care of themselves at home, however, despite recurrent education opportunities it does not correlate. Actions Identified Simple education tool (patient-centered) Increase referrals to dietitian and cardiac rehab Expanded teach back and motivational interviewing education and/or reeducation 21

22 Recommendations: Action Plan and Goals Primary prevention Heart healthy lifestyle; including dietitian referrals Expanded teach back and motivational interviewing education and/or reeducation Secondary prevention Simple education tool (patient-centered) Tertiary prevention Cardiac rehab (which could be secondary also) Recommendations: implementation Plan PDSA Cycle of Improvement Self-Determination Theory of Change 22

23 Recommendations: Cost of Action Plan Staff time Trainer and trainee Education time: new tool=more time Time used to bring back education to team members Increase referrals=more time with dietitian and cardiac rehab specialist Although this could be a revenue generator Printing costs Recommendations: Evaluation Reduction in readmissions for CHF (ultimately reduction In admissions) Reduction of emergency room visits for CHF Improvements in patient satisfaction surveys Hospital Clinic Home care Nursing facility Patient report 23

24 Summary Recap Thank you Reference list available upon request SAFE Transitions Roadmap Jen P

25 Contact Info Janelle Shearer, Stratis Health Heather Keyes, Stratis Health This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-C